Triplane fracture
Updates to Article Attributes
Triplane or triplanar fractures are of the distal tibia only occurring in adolescents. As the physiological closure of the physeal plate begins medially, the lateral (open) physis is prone to this type of fracture. The name is due to the fact of the fracture expanding both in frontal and lateral as well as transverse planes. Most authors regard it as a type IV Salter-Harris fracture.
It comprises of:
- a vertical fracture through the epiphysis
- a horizontal fracture through the physis
- an oblique fracture through the metaphysis
As physeal closure has to begin at an end, triplane fractures have occasionally been reported in other sites too, e.g. distal radius 2, proximal tibia 4, distal femur 5.
Epidemiology
In adolescents with closing epiphyseal plate(s) they are the most common ankle joint fractures - along with Tillaux fractures.
Clinical presentation
Symptoms comprise of pain and inability to weight bear. Possible signs include swelling, localised/referred pain, and/or deformity of the ankle.
Pathology
Mechanism
External rotation and supination is considered to be the main injury mechanism of the tibial typeinjury in lateral triplane fractures. The uncommon medial variation usually occurs with an adduction force 9.
Radiographic features
Plain radiograph
Standard ankle series suggested; AP, lateral and Mortise (best view to define displacement). Due to the aforementioned characteristics, the fracture typically appears in routine projections as follows:resembles;
-
resemblingSalter-Harris III fracture on APviews -
resemblingSalter-Harris II fracture on lateralviews
Small dislocations and the vertical fracture itself are not infrequentlyfrequently overlooked, why in cases of doubt itand CT is advisable to performadvised if there is concern.
CT
The imaging modality of choice, permitting identification of.;
- fracture
shape i.e. fracture type itselfpattern and articular congruity -
fragment number
of fragments -
orientationanddislocation of fragment(s)orientation/relationship
For the same reasons, CT aids in treatment planning as well 6.
MRI
May be used to reveal associated ligamentligamenteous injuries, osteochondral fractures and chondral fractures 7.
Treatment and prognosis
Treatment options comprise of surgery (i.e. open reduction and internal fixation - ORIF) and conservative management (i.e. long leg cast immobilization). Physeal arrest leadingmay occur in 7% to 21% of cases, which may rarely lead to angular deformity may occur. The significance of preserving the physis is questionable given the limited remaining growth potential, but is considered rarepatients with greater than 2 years of growth remaining should be followed.
History and etymology
The term was coined by L Marmor in 1970 8.
Differential diagnosis
On radiographs, possible considerations include;
-</ul><p>As physeal closure has to begin at an end, triplane fractures have occasionally been reported in other sites too, e.g. distal radius <sup>2</sup>, proximal tibia <sup>4</sup>, distal femur <sup>5</sup>.</p><h4>Epidemiology</h4><p>In adolescents with closing epiphyseal plate(s) they are the most common ankle joint fractures - along with <a href="/articles/tillaux-fracture">Tillaux fractures</a>.</p><h4>Clinical presentation</h4><p>Symptoms comprise of pain and inability to weight bear. Possible signs include swelling, localised/referred pain, and/or deformity of the ankle</p><h4>Pathology</h4><h5>Mechanism</h5><p>External rotation is considered to be the main injury mechanism of the tibial type.</p><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Due to the aforementioned characteristics the fracture typically appears in routine projections as follows:</p><ul>-<li>resembling <a href="/articles/salter-harris-classification">Salter-Harris III fracture</a> on AP views</li>-<li>resembling <a href="/articles/salter-harris-classification">Salter-Harris II fracture</a> on lateral views</li>-</ul><p>Small dislocations and the vertical fracture itself are not infrequently overlooked, why in cases of doubt it is advisable to perform</p><h5>CT</h5><p>The imaging modality of choice, permitting identification of.</p><ul>-<li>fracture shape i.e. fracture type itself</li>-<li>number of fragments</li>-<li>orientation and dislocation of fragment(s)</li>-</ul><p>For the same reasons CT aids in treatment planning as well <sup>6</sup>.</p><h5>MRI</h5><p>May be used to reveal associated ligament injuries, <a title="Osteochondral fractures" href="/articles/osteochondral-fracture">osteochondral fractures</a> and/or <a title="Chondral fractures" href="/articles/chondral-fracture">chondral fractures</a> <sup>7</sup>.</p><h4>Treatment and prognosis</h4><p>Treatment options comprise surgery (i.e. <a href="/articles/orif">open reduction and internal fixation</a> - ORIF) and conservative management (i.e. long leg cast immobilization). Physeal arrest leading to angular deformity may occur but is considered rare.</p><h4>History and etymology</h4><p>The term was coined by <strong>L Marmor</strong> in 1970 <sup>8</sup>.</p><h4>Differential diagnosis</h4><p>On radiographs, possible considerations include</p><ul><li><a href="/articles/tillaux-fracture">Tillaux fracture</a></li></ul>- +</ul><p>As physeal closure has to begin at an end, triplane fractures have occasionally been reported in other sites too, e.g. distal radius <sup>2</sup>, proximal tibia <sup>4</sup>, distal femur <sup>5</sup>.</p><h4>Epidemiology</h4><p>In adolescents with closing epiphyseal plate(s) they are the most common ankle joint fractures - along with <a href="/articles/tillaux-fracture">Tillaux fractures</a>.</p><h4>Clinical presentation</h4><p>Symptoms comprise of pain and inability to weight bear. Possible signs include swelling, localised/referred pain, and/or deformity of the ankle.</p><h4>Pathology</h4><h5>Mechanism</h5><p>External rotation and supination is the main mechanism of injury in lateral triplane fractures. The uncommon medial variation usually occurs with an adduction force <sup>9</sup>.</p><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Standard ankle series suggested; AP, lateral and Mortise (best view to define displacement). Due to the aforementioned characteristics, the fracture typically resembles;</p><ul>
- +<li>
- +<a href="/articles/salter-harris-classification">Salter-Harris III fracture</a> on AP </li>
- +<li>
- +<a href="/articles/salter-harris-classification">Salter-Harris II fracture</a> on lateral </li>
- +</ul><p>Small dislocations and the vertical fracture itself are frequently overlooked, and CT is advised if there is concern. </p><h5>CT</h5><p>The imaging modality of choice, permitting identification of;</p><ul>
- +<li>fracture pattern and articular congruity</li>
- +<li>fragment number and orientation/relationship</li>
- +</ul><p>For the same reasons, CT aids in treatment planning as well <sup>6</sup>.</p><h5>MRI</h5><p>May be used to reveal associated ligamenteous injuries, <a href="/articles/osteochondral-fracture">osteochondral fractures</a> and <a href="/articles/chondral-fracture">chondral fractures</a> <sup>7</sup>.</p><h4>Treatment and prognosis</h4><p>Treatment options comprise of surgery (i.e. <a href="/articles/orif">open reduction and internal fixation</a> - ORIF) and conservative management (i.e. long leg cast immobilization). Physeal arrest may occur in 7% to 21% of cases, which may rarely lead to angular deformity. The significance of preserving the physis is questionable given the limited remaining growth potential, but patients with greater than 2 years of growth remaining should be followed.</p><h4>History and etymology</h4><p>The term was coined by <strong>L Marmor</strong> in 1970 <sup>8</sup>.</p><h4>Differential diagnosis</h4><p>On radiographs, possible considerations include;</p><ul><li><a href="/articles/tillaux-fracture">Tillaux fracture</a></li></ul>
References changed:
- 9. Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. (2013) The Journal of the American Academy of Orthopaedic Surgeons. 21 (4): 234-44. <a href="https://doi.org/10.5435/JAAOS-21-04-234">doi:10.5435/JAAOS-21-04-234</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23545729">Pubmed</a> <span class="ref_v4"></span>
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